Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on March 30, 2021, FMC Dialysis Services - Donora was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed March 30, 2021, FMC Dialysis Services - Donora was identified to have the following standard level deficiency that was determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Blood pressure, and fluid management needs.
Observations:
Based on review of facility policy, medical records (CR), and interview with facility staff, the facility failed to obtain physician orders for the management of patient's blood pressure and/or fluid management needs for two (2) of five (5) CR's reviewed. (CR2, CR4).
Findings Included:
Review of agency policy on 3/30/2021 at approximately 11:50 PM revealed: "...Policy: ...Management and Prevention of Hypotension...Purpose...recognition and appropriate treatment of symptomatic reduction of blood pressure...and associated complications... Treating Hypotension while on Hemodialysis...1. Obtain blood pressure...Verify BP (blood pressure) ... 4. Administer a normal saline bolus (NSS) of 100-200mls (milliliters) as ordered by the physician. Recheck BP and pulse. Administer additional saline boluses if needed based on patient ' s symptoms. 5 If blood pressure does not respond to saline bolus, under the direction of the RN or supervising nurse, additional saline may be given, or RN may administer IV (intravenous) medications as prescribed by patient ' s physician/standing orders. Note: Rapid infusion of a large bolus of saline may cause dysrhythmia or flash pulmonary edema. ... Notify the Charge Nurse or Team Leader if: Patient experiences hypotension...Notify the Charge Nurse or Team Leader and the patient's Nephrologist if: Patient's hypotension does not respond to intervention...Document in the patient's medical record vital signs, interventions, patient responses, conversations with the patient, physicians, and physician orders..."
CR2, admission 6/4/2020, reviewed on 3/29/2021 at approximately 1 PM. Review of treatment records dated 3/6/2021 through 3/25/2021 revealed:
3/9/2021, Treatment Data:
BP 146/72 at 12:11 PM "Resting comfortably, access visible, RN notified, ...denies complaints; Patient alert; Bp rechecked, gave 100 nss" documented by PCT1.
BP 110/52 at 1:06 PM, "Resting comfortably, access visible ... denies complaints; patient alert ... gave 200 nss, repositioned cuff and rechecked bp. RN aware" documented by PCT1.
3/20/2021, Treatment Data:
BP 95/52 at 1:26 PM "Resting comfortably, access visible, RN notified, Patient alert; per RN1 gave 200 nss for low b/p" documented at 1:27 PM by PCT2.
3/23/2021, Treatment Data:
BP 83/38 at 10:30 AM "Denies complaints; patient alert; RN2 notified of low b/p" documented by PCT2.
BP 70/36 at 11:00 AM "RN notified; patient alert; access visible; patient given 600 nss for being non responsive. Pt awake to take medication." Documented by PCT2.
There was no physician's order in CR2's medical record for the administration of normal saline as an intervention in response to hypotension.
CR4, admission 1/2/2019, reviewed on 3/30/2021 at approximately 11:30 AM. Review of treatment records dated 3/6/2021 through 3/25/2021 revealed:
3/16/2021, Treatment Data:
BP 111/55 at 7:03 AM, "Pt states gi [stomach] upset. ... 200cc nss given" documented by RN3.
3/23/2021, Treatment Data:
BP 95/54 at 8:02 AM, "Access visible, saline per RN" [200 listed as fluid administered] by PCT3.
BP 83/47 at 8:29 AM, "Denies complaints, Access visible, low BP, gave 100ns ..." documented by RN2.
3/25/2021, Treatment Data:
BP 89/52 at 9:47 AM, "Denies complaints, low bp ...gave 200 ns RN aware," documented by PCT4.
There was no physician's order in CR4's medical record for the administration of normal saline as an intervention in response to hypotension.
An exit conference was conducted on 3/30/2021 at approximately 2:00PM with facility Administrator (EMP1), and Director of Operations (EMP3) Above findings were reviewed.
Plan of Correction:V 504
For immediate compliance on 4/13/21, physician orders were obtained and entered in all patients' medical records for prn administration of normal saline in the event of hypotension.
The Clinic Manager (CM) or designee will educate the DPC staff on:
- Complications of Hemodialysis-Management and Prevention of Hypotension
Emphasis will be placed on ensuring that blood pressures (BP) are monitored every 30 minutes and all episodes of hypotension are reported to the RN for further evaluation and intervention. The meeting will review that the physician's order must be followed for the administration of normal saline for the treatment of hypotensive episodes. The meeting also reinforced the importance of the RN documentation of the hypotension and interventions taken.
Documentation of the in-service is on file at the facility.
The CM or designee will complete daily audits of 15% of random flowsheets for 2 weeks. If 100% compliance is noted, the audits will be completed two 2 times/week for 2 weeks. At that time, if compliance is being sustained the audits will be completed monthly. A POC audit tool will be used for the audits
Non-adherence will result in re-education and counseling.
All audit findings will be reviewed by the CM monthly during QAI meetings. Sustained compliance will be monitored by the QAI committee.
Completion Date: 5/3/21
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